Learn: Learn

Untenable expectations: nurses’ Work in the context of medication administration, error, and the organization (13 November 2022)

Mon, 06 Feb 2023 17:29:00 +0000

Positive approaches to safety: Learning from what we do well (18 June 2022)

Tue, 16 Aug 2022 16:25:00 +0000

This article from Adrian Plunkett and Emma Plunkett, discusses some of the theoretical limitations of the prevailing approach to patient safety and introduce emerging, complementary approaches in this field of practice. Safety-II and resilience engineering represent a new paradigm of safety, characterised by focusing on the entirety of work, with a system-wide lens, rather than single incidents of failure. More overtly positive approaches are available, specifically focusing on success—both outstanding success and everyday success—including exnovation, appreciative inquiry, learning from excellence and positive deviance. These approaches are not mutually exclusive. The new methods described in this article are not intended as replacements of the current methods, rather they are presented as complementary tools, designed to allow the reader to take a balanced and holistic view of patient safety.

The past and present of System-Theoretic Accident Model And Processes (STAMP) and its associated techniques: A scoping review (9 November 2021)

Wed, 10 Nov 2021 15:10:32 +0000

Highlights

STAMP, STPA and CAST are well-established approaches to system safety analysis.
Not all academic publications offer full coverage of analytical steps and results.
Many papers suggest various modifications and extensions of the original approaches.
Publications are documented across various industries and lifecycle stages.
Industry engagement has not been visible in the majority of publications.

Management of patient-reported outcome (PRO) alerts in clinical trials: A cross sectional survey (19 January 2016)

Fri, 05 Nov 2021 16:10:31 +0000

From dissemination to engagement: learning over time from a national research intermediary centre (Four Fs) (21 October 2021)

Tue, 02 Nov 2021 13:55:33 +0000

Key messages

There is little shared learning on the practice of evidence use by knowledge intermediaries.
Our account of a national evidence centre for health decision makers shows the shift towards more engaged and embedded approaches.
We identify four central activities – filter, forge, fuse and fulfil – and how they evolved over time.
We note the value of sustained engagement with stakeholders in shaping new evidence narratives relevant to practice.

Before/after intervention study to determine impact on life-cycle carbon footprint of converting from single-use to reusable sharps containers in 40 UK NHS trusts (27 September 2021)

Fri, 15 Oct 2021 15:43:00 +0000

Survey of nurses’ experiences applying The Joint Commission’s Medication Management Titration Standards (1 September 2021)

Fri, 08 Oct 2021 11:58:00 +0000

A systematic review and meta-analysis on the impact of proficiency-based progression simulation training on performance outcomes (1 August 2021)

Wed, 15 Sep 2021 18:13:00 +0000

Shadow coaching improves patient experience with care, but gains erode later (12 August 2021)

Tue, 07 Sep 2021 15:22:35 +0000

Health-system pharmacy department safety huddles: An evaluation of current practice and perceived best practice (28 July 2021)

Sat, 04 Sep 2021 17:15:00 +0000

Pharmacist’s review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

Tue, 17 Aug 2021 10:53:00 +0000

Schwartz Rounds publications

Wed, 21 Apr 2021 08:56:26 +0000

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: A scoping review (3 November 2021)

Mon, 01 Mar 2021 13:07:00 +0000

Explaining Michigan: Developing an ex post theory of a quality improvement program (16 June 2011)

Sat, 19 Dec 2020 18:56:00 +0000

Predicting scheduled hospital attendance with artificial intelligence (12 April 2019)

Thu, 12 Nov 2020 16:49:00 +0000

People, systems and safety: resilience and excellence in healthcare practice (25 December 2018)

Mon, 26 Oct 2020 03:00:00 +0000

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs (7 October 2015)

Tue, 20 Oct 2020 15:41:00 +0000

Safety clutter: the accumulation and persistence of ‘safety’ work that does not contribute to operational safety (17 August 2018)

Thu, 24 Sep 2020 15:44:00 +0000

Safety clutter is the accumulation of safety procedures, documents, roles, and activities that are performed in the name of safety, but do not contribute to the safety of operations. Safety clutter is a problem because of the opportunity cost of ineffective activity, because clutter results in cynicism and ‘surface compliance,’ and because clutter can hamper innovation and get in the way of getting work done.

The authors of this paper identify three main mechanisms that generate clutter: duplication, generalisation, and over-specification of safety activities. These mechanisms in turn are driven by asymmetry between the ease and the opportunity of adding or expanding safety activities, and the difficulty and lack of opportunity for reducing or removing safety activities.

At the end of the paper, the authors provide some concrete suggestions for reducing safety clutter, based on our analysis of the problem.

Strengthening patient safety in transitions of care: an emerging role for local medical centres in Norway (30 August 2016)

Sun, 13 Sep 2020 14:24:00 +0000

The use of patient monitoring systems to improve sepsis recognition and outcomes: A systematic review (September 2020)

Tue, 25 Aug 2020 17:31:00 +0000

Good and bad reasons: The Swiss cheese model and its critics (June 2020)

Thu, 20 Aug 2020 11:30:00 +0000

Effects of skin pigmentation on pulse oximeter accuracy at low saturation (2005)

Fri, 07 Aug 2020 10:49:00 +0000

Restorative just culture: a study of the practical and economic effects of implementing restorative justice in an NHS Trust (January 2019)

Thu, 30 Jul 2020 10:44:00 +0000

Race, postoperative complications, and death in apparently healthy children (July 2020)

Tue, 28 Jul 2020 13:37:59 +0000

Policies vs practice of medical error disclosure at a teaching hospital in Saudi Arabia (May 2020)

Mon, 27 Jul 2020 23:30:00 +0000